Citation Nr: 21065559 Decision Date: 10/26/21 Archive Date: 10/26/21 DOCKET NO. 17-40 210 DATE: October 26, 2021 ORDER Entitlement to service connection for a headache disability, to include migraine and migraine variants, is granted. REMANDED Entitlement to service connection for choroidal nevus right eye is remanded. Entitlement to service connection for a conjunctivitis disability, to include herpes keratitis is remanded. Entitlement to service connection for ptosis is remanded. Entitlement to an initial compensable rating for service-connected dry eye is remanded. FINDING OF FACT The evidence is at least in equipoise that the Veteran's headache disability, to include migraine and migraine variants, is proximately due to residuals of his service-connected cataract repair surgery. CONCLUSION OF LAW The criteria for service connection for a headache disability, to include migraine and migraine variants, as secondary to residuals of service-connected cataract repair surgery are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Army from July 1970 to March 1972, including service in Vietnam. The Board thanks the Veteran for his service. This matter is before the Board of Veterans' Appeals (Board) on appeal from a March 2016 rating decision. 1. Entitlement to service connection for headaches The Veteran contends that his headache disability began after his service-connected cataract repair surgery and that it is causally related to the surgery and/or its residuals. Service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). A Disability Benefits Questionnaire (DBQ) received in September 2015, (completed by the Veteran's treating ophthalmologist, Dr. D.D.) states that the Veteran's service-connected cataract repair surgery is responsible for causing blurred vision, reduced field of vision, and floaters in the right eye. It then opines that the Veteran experiences "headaches caused by blurred vision and floaters." Additionally, a January 2016 VA examination shows the Veteran has a current disability of "migraine including migraine variants." The VA examiner declined to provide a nexus opinion but reported that the Veteran's migraines began after his cataract repair surgery. Upon review of the record, the Board finds the evidence to at least be in equipoise as to whether the Veteran's current headache disability, to include migraine and migraine variants, is proximately due to residuals of his service-connected cataract surgery. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for a headache disability is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. REASONS FOR REMAND 1. Entitlement to service connection for choroidal nevus of the right eye is remanded. The Board cannot make a fully-informed decision on the issue of entitlement to service connection for choroidal nevus of the right eye because no VA examiner has opined whether it was at least as likely as not proximately due to or aggravated by the Veteran's service-connected cataract repair surgery. Although though the May 2017 Statement of the Case concluded that choroidal nevus "is not considered a disability for the purposes of compensation but a congenital or developmental abnormality," there is no medical information of record to support that finding. Rather, a DBQ received in September 2015 indicates that the Veteran's choroidal nevus is a benign tumor or neoplasm and requires "watchful waiting." Thus, the Board finds that remand is required to obtain an addendum opinion regading the etiology of the choroidal nevus. 2. Entitlement to service connection for a conjunctivitis disability, to include herpes keratitis is remanded. The Board cannot make a fully-informed decision on the issue of entitlement to service connection for a conjunctivitis disability, to include herpes keratitis, because no VA examiner has opined whether the disability is at least as likely as not proximately due to or aggravated by the Veteran's service-connected cataract repair surgery. Thus, the Board finds that remand is required to obtain an addendum opinion regarding the etiology of the conjunctiitis disability. 3. Entitlement to service connection for ptosis is remanded. The Board cannot make a fully-informed decision on the issue of entitlement to service connection for ptosis, diagnosed as herpes keratitis, because no VA examiner has opined whether the disability is at least as likely as not proximately due to or aggravated by the Veteran's service-connected cataract repair surgery. The Veteran has submitted citation to medical studies showing a relationship between ptosis and cataract repair surgery, particularly with the use of an eyelid speculum as in this Veteran's case. See Notice of Disagreement (NOD) received May 2016. Thus, the Board finds that remand is required to obtain an addendum opinion regarding the etiology of the Veteran's ptosis. 4. Entitlement to an initial compensable rating for service-connected dry eye is remanded. Regarding the claim of entitlement to an initial compensable rating for service-connected dry eye, the Veteran submitted a timely notice of disagreement with the March 2016 rating decision, but a statement of the case has not yet been issued. The May 2016 NOD states that the Veteran seeks a 10 percent rating, and argues that the disability should be rated by analogy to Diagnostic Code 6018 because the symptoms more accurately reflect the functional impairment of dry eye than rating based on loss of visual acuity. A remand is required for the AOJ to issue a statement of the case. 38 C.F.R. § 20.200; Manlincon v. West, 12 Vet. App. 238, 240-41 (1999). The matters are REMANDED for the following action: 1. Attempt to associate with the record all outstanding VA and non-VA treatment records. 2. Obtain an addendum opinion from an appropriate clinician regarding the Veteran's choroidal nevus of the right eye, conjunctivitis disability (to include herpes keratitis), and ptosis. The Veteran's claim file must be made available for the clinician for review before rendering an opinion. An in-person examination should only be scheduled if the clinician determines it is necessary to provide the requested opinions. After review of the claim file, the clinician must opine as to the following: (a.) Whether the Veteran's choroidal nevus of the right eye is at least as likely as not proximately due to service-connected disability, to include cataracts or cataract repair surgery; and (b.) Whether the Veteran's choroidal nevus of the right eye is at least as likely as not aggravated by (any increase in disability) service-connected disability, to include cataracts or cataract repair surgery. The clinician should consider and discuss as relevant the September 2015 DBQ indicating that the Veteran's choroidal nevus was diagnosed in September 2015, after his cataract surgery. (c.) Whether the Veteran's conjunctivitis disability, to include herpes keratitis, is at least as likely as not proximately due to service-connected disability, to include cataracts or cataract repair surgery. (d.) Whether the Veteran's conjunctivitis disability, to include herpes keratitis, is at least as likely as not aggravated by (any increase in disability) service-connected disability, to include cataracts or cataract repair surgery (e.) Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran's ptosis is at least as likely as not proximately due to service-connected disability. (f.) Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran's ptosis is at least as likely as not aggravated by (any increase in disability) service-connected disability. The clinician should consider and discuss as relevant the following: An August 2014 medical treatment record (prior to cataract surgery) noting a secondary diagnosis of dermatochalasis but not describing any related symptoms or effects. A September 2015 DBQ (after cataract surgery) indicating a referral for blepharoplasty OU due to dermatochalasis and blepharitis. The DBQ also notes that bilateral ptosis caused a decrease in visual acuity. A December 2015 medical treatment record (received January 2016) stating the Veteran requires eyelid taping to perform vision field assessment due to "very droopy lids[.]" Medical studies cited in the May 2016 NOD discussing the relationship between cataract surgery and ptosis, particularly when a speculum was used as in this Veteran's case. The NOD file includes his operative report as an attachment. 3. Send the Veteran and his representative a statement of the case that addresses the issue of entitlement to an initial compensable rating for service-connected dry eye. If the Veteran perfects an appeal by submitting a timely VA Form 9, the issue should be returned to the Board for further appellate consideration. M. C. GRAHAM Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Beeler, C. The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.